What is the first line management for patients presenting with chest pain according to the Philippine guidelines?

First-Line Management of Chest Pain in the Philippine Guidelines

I was unable to locate specific Philippine national guidelines for chest pain management in the provided evidence. However, the fundamental approach to chest pain management follows internationally recognized protocols that prioritize rapid identification and treatment of life-threatening conditions, particularly acute coronary syndrome (ACS).

Immediate Assessment (Within 10 Minutes)

All patients presenting with chest pain should receive a 12-lead ECG within 10 minutes of arrival and be placed on continuous cardiac monitoring with a defibrillator readily available. 1, 2

Critical Initial Actions:

• Obtain vital signs immediately including heart rate, blood pressure, respiratory rate, and oxygen saturation 1
• Establish intravenous access as soon as possible 1
• Administer aspirin 250-500 mg (chewable or water-soluble) immediately if ACS is suspected and no contraindications exist 2
• Provide pain relief with morphine titrated intravenously according to pain severity, as pain itself causes sympathetic activation and increased blood pressure 1

Focused History and Physical Examination

Obtain a targeted history within 5 minutes focusing on specific chest pain characteristics that predict cardiac origin: 1

Key Historical Features to Assess:

• Nature of pain: retrosternal discomfort that builds gradually over several minutes 1
• Onset and duration: acute onset with prolonged duration suggests life-threatening conditions 2
• Location and radiation: characteristic radiation to left arm, neck, or jaw 1
• Precipitating factors: physical or emotional stress, or occurring at rest 1
• Associated symptoms: diaphoresis, nausea/vomiting, dyspnea, lightheadedness, or syncope 1, 3
• Cardiovascular risk factors: age, sex, diabetes, hypertension, smoking, family history 1

Important caveat: Relief with nitroglycerin should NOT be used as a diagnostic criterion, as other conditions (such as esophageal spasm) may respond similarly 1, 2

Risk Stratification Based on ECG Findings

High-Risk Features (Immediate Intervention Required):

If ST-segment elevation, new ST depression, or new left bundle branch block is present, activate reperfusion protocols immediately with thrombolytic therapy started within 30 minutes or arrange for primary percutaneous coronary intervention. 1

Additional high-risk indicators requiring coronary care unit admission: 1

• Severe continuing pain
• Positive troponin test
• Left ventricular failure
• Hemodynamic instability
• Major arrhythmias

Intermediate-Risk Features:

For patients with ST-segment depression or T-wave changes without ST elevation: 1

• Draw blood samples for cardiac troponin (CK-MB mass and troponin T or I) on admission 1
• Repeat troponin at 10-12 hours after symptom onset 1
• Initiate low-molecular-weight heparin or unfractionated heparin 1, 4
• Administer beta-blockers intravenously if tachycardia or hypertension present 1
• Give sublingual or intravenous nitrates for ongoing chest pain 1, 4

Normal or Nondiagnostic ECG:

Patients with normal ECG and normal initial biomarkers but severe chest pain require careful evaluation for other life-threatening conditions including pulmonary embolism, aortic dissection, acute pericarditis, and pneumothorax 1

Perform serial ECGs if clinical suspicion remains high, symptoms persist, or clinical condition deteriorates. 4, 2

Additional Diagnostic Testing

• Chest X-ray to evaluate for pneumonia, pneumothorax, widened mediastinum (aortic dissection), or heart failure 1, 4
• Consider supplemental ECG leads V7-V9 if posterior myocardial infarction is suspected 4, 2

Pharmacologic Management

For Suspected ACS:

The following medications should be initiated in the emergency department: 1, 4

• Aspirin 75-250 mg (or clopidogrel if aspirin contraindicated)
• Beta-blockers (target heart rate <60 beats/min) unless contraindicated by bradycardia, hypotension, or heart failure 1
• Nitrates (sublingual or intravenous) for persistent/recurrent chest pain, avoiding use in hypotension or bradycardia 2
• Low-molecular-weight heparin or unfractionated heparin for elevated troponin or high-risk features 1
• Target systolic blood pressure 100-120 mmHg in the absence of neurological complications 1

Pain Management:

Morphine remains the preferred analgesic, given intravenously and titrated to effect 1

Disposition and Observation

Patients without high-risk features should be observed in a chest pain unit for 10-12 hours after symptom onset rather than discharged directly from the emergency department, as the risk of missed ACS is unacceptably high without proper observation 1

The chest pain unit should be equipped with: 1

• Resuscitation equipment
• Cardiac rhythm monitoring with arrhythmia alarms
• Blood pressure and oxygen saturation monitoring
• Continuous ST-segment monitoring capability

Critical Pitfalls to Avoid

• Never delay transfer or treatment to obtain troponin results in the office setting if ACS is suspected 4
• Do not rely on symptom intensity to gauge severity, as there is frequently poor correlation between symptom intensity and disease seriousness 1, 2
• Recognize atypical presentations in women, elderly patients, and those with diabetes, who may present with dyspnea, nausea, or vague abdominal symptoms rather than classic chest pain 1, 2
• Avoid using nitroglycerin response as a diagnostic test for cardiac ischemia 1, 2
• Be cautious with nitroglycerin in patients who may be volume-depleted or hypotensive, as severe hypotension may occur 5

Transport Considerations

Patients with clinical evidence of ACS or life-threatening chest pain should be transported urgently to the emergency department, ideally by emergency medical services rather than private vehicle. 2